Medical Officer - Specialist 1

Job Description -Pre-authorization

Job Purpose

To evaluate and adjudicate pre-authorization requests by reviewing medical details, policy terms, and insurer concurrence, ensuring accurate and timely approvals that contribute to effective processing and customer satisfaction.

Principal Accountabilities

• •Process pre-authorization requests : Ensure timely and accurate adjudication (approval, rejection, or shortfall) - compliance with policy terms.
• •Review and validate medical details : Check system entries and documents - maintain accuracy and reduce errors.
• •Refer cases requiring specialist input : Escalate package deviations or complex cases -ensure appropriate medical decision-making.
• •Coordinate with insurers : Obtain concurrence for approvals - smooth case closure and in line with Insurer guidelines.
• •Respond to medical queries from hospitals/customers : Provide clear communication - enhance customer experience.
• •Follow internal guidelines and regulatory standards : Maintain compliance - minimize audit observations.

Reporting Structure:

Reports To: Floor Manager – Pre-Auth

Major Challenges

• •Managing high volumes of pre-auth requests within defined TAT.
• •Managing accuracy with speed in decision-making.
• •Handling escalations and complex medical cases effectively.
• •Query Management with hospitals, insurers, and internal teams for quick resolutions.

Decisions

• •Independent: Adjudication of standard pre-authorization cases as per policy terms.
• •With Approval: Escalations requiring specialist opinion, insurer concurrence, or deviations from package norms.

Interactions

Internal: Pre-Auth Team, Case Management, CRM team.

External:

• •Hospitals through Query (for discharge summaries, clarifications, and missing documents).
• •Insurers (for concurrence and escalations).

Qualifications & Experience

• •Education: Graduates -BHMS/BAMS/BDS
• •Experience:
• •Fresher medical graduates can apply.
• •Prior experience in Pre-Authorization in a TPA or HealthTech setup preferred.
• •Exposure to authorization processes is an added advantage.

Other requirements:

• •Strong medical knowledge with willingness to work in a non-clinical process.
• •Prior experience in pre-authorization or claims (preferred).
• •Flexible to work in shifts and from office (no WFH).
• •Prior HealthTech / TPA experience is an advantage.